CQC report explained · a residential care home
What the CQC found at Belvoir House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People's individual risks, medicines, staffing, recruitment and infection control had improved. Inspectors identified further actions to manage legionella risk, which the provider took during the inspection.
- Effective?
- Good
- People's needs and capacity were assessed, staff training and supervision had improved, and people received suitable food, drink and health care. Some areas of the building were still tired and needed refurbishment.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported independence, protected privacy and involved people and relatives more regularly in decisions about care.
- Responsive?
- Good
- Care plans contained more detailed information about people's histories, preferences, communication and routines. Activities had increased and were shaped by people's interests.
- Well-led?
- Good
- The new management arrangements had improved the culture, communication and oversight of care. Inspectors said the electronic care management system needed more work to become fully embedded and effective.
What inspectors found, April 2023
Belvoir House is rated Good and is no longer in Special Measures; inspectors found major improvements, with some work still needed on the building and new systems.
Inspectors visited unannounced on 7 March 2023. They observed care, spoke with people, relatives and staff, and checked care, medicines, recruitment, training, safety and management records. They also checked infection prevention and control.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer recruitment, improved cleanliness, safer medicines, better care planning and kind, respectful support. Food, activities, communication and involvement in care had also improved.
The previous inspection had rated the home Inadequate overall, and it had been in Special Measures since July 2022. Conditions had been placed on the provider's registration. At this inspection, inspectors found the home was no longer breaching regulations and was no longer in Special Measures.
Staffing and safety
The home had reviewed staffing levels and increased them during the day and night. People were supported by staff who had been recruited with appropriate checks.
“People, relatives, and staff told us there were enough staff.” from the report
Kind and respectful care
Staff were attentive, encouraged independence and respected people's privacy and dignity during personal care.
“We observed staff were attentive to people, gently supporting them whilst encouraging independence.” from the report
Personalised support
Care plans included people's life histories, interests, communication needs and daily preferences. Staff were observed using this information in their support.
“People received person-centred care from staff who knew them well, including their individual needs, social histories, and interests.” from the report
Activities and relationships
The home offered more regular group and individual activities, including outings. People were asked what activities they wanted.
“The activities on offer and support around social isolation had increased significantly.” from the report
Improved leadership
Inspectors found a more open and positive culture, with better communication and systems for people, relatives and staff to give feedback.
“The culture within the service was much more person centred.” from the report
Refurbishment was still under way
minorSome parts of the home were tired and needed refurbishment. A refurbishment plan was in place and some work had already started.
“Some areas of the home were tired and required refurbishment.” from the report
New care system not fully embedded
needs fixingThe electronic care management system had been introduced, but inspectors said more work was needed to make sure it was fully effective.
“Some further work was required to ensure this was fully embedded and effective.” from the report
Legionella risk needed action
needs fixingInspectors found that further action was needed to manage legionella risk robustly. The provider acted during the inspection and inspectors were assured the risk had been reduced.
“We identified some further actions were required to robustly manage the risk of legionella.” from the report
- 01What refurbishment work remains, and when is it expected to be completed?
- 02How do you check that the electronic care management system is accurate and being used properly?
- 03How are legionella checks and other environmental risks monitored now?
- 04Who is responsible for managing the home while the application for a registered manager is considered?
- 05How will you make sure the improvements found at this inspection continue?
This was an unannounced inspection covering all five key questions, including infection prevention and control, and it looked at both the premises and the care provided. This explanation was written from the published report of 14 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2022
Rated Inadequate and placed in special measures; inspectors found serious concerns about safety, dignity, staffing and management.
This was an unannounced inspection. Inspectors visited on 28 June 2022 and continued checking records remotely until 5 July. They observed care, spoke with people, relatives, staff and health professionals, and reviewed care, medicines, staffing and governance records.
Inspectors found serious and widespread problems. Risks were not always identified or managed, people sometimes waited while distressed, and some care was undignified and not personalised. The home also failed to follow the Mental Capacity Act consistently, and care records were often inaccurate, incomplete or not reviewed regularly.
Food and drink were generally available, people usually received their oral medicines as prescribed, and some staff knew people's needs well. A new manager and senior managers had begun making changes, but the inspection found that the problems were still present.
The overall rating was Inadequate. Safe and well-led were Inadequate, while Effective, Caring and Responsive were Requires Improvement. The home was placed in special measures and CQC said it would continue to monitor progress.
Food and drink
People were offered a choice of food and enough to eat and drink. Relatives said they had no concerns about people receiving enough to drink.
“People's nutritional needs were met, and they were offered choice and enough to eat and drink however associated assessments had not always been completed in a timely manner.” from the report
Oral medicines
People generally received their oral medicines as prescribed. Medicines were stored securely and at the correct temperatures.
“Oral medicines were stored securely and at correct temperatures and staff had received training on medicine management and had been assessed as competent to give people their medicines.” from the report
Personalised bedrooms
Bedrooms reflected people's individuality, and memory boxes helped some people find their rooms independently.
“People's bedrooms were personalised and that memory boxes were in place to help people independently navigate to their rooms.” from the report
Action after inspection
Once the problems were identified, the provider took prompt steps including additional management cover, reviews and a service improvement plan.
“The provider has taken swift action in response to their own findings and this inspection.” from the report
Risks were not managed
seriousImportant risks, including weight loss, swallowing problems, skin damage and leaving the home, were not always assessed or acted on. This could leave people at risk of avoidable harm.
“The individual risks to people had not been fully identified, assessed and managed.” from the report
Undignified care
seriousSome people waited for continence support while distressed. Inspectors also saw a hoist transfer carried out in a communal area without enough preparation or protection of privacy.
“We saw examples of disrespectful and undignified care that failed to consider people's privacy and independence.” from the report
Staffing and recruitment
seriousRecruitment files had gaps and one person's previous convictions had not been robustly assessed. People sometimes waited too long for help because staff did not have enough time to support them promptly.
“During our inspection, we saw that people had to wait for assistance.” from the report
Consent and restrictive practices
seriousThe home did not consistently assess people's mental capacity or record best-interest decisions. There were no records showing that sensor mats had been used in people's best interests.
“The service continued to fail to work to MCA legislation.” from the report
Limited activities
needs fixingPeople were not consistently supported to follow their interests or avoid social isolation. There was no activities schedule and inspectors saw few meaningful activities.
“The feedback received, and our observations on the inspection site visit, confirmed that people did not receive support to follow their interests or take part in activities.” from the report
Weak oversight
seriousThe provider's monitoring systems did not identify serious problems quickly. Complaints, incidents and medicines errors were not consistently analysed to identify learning.
“The provider's quality monitoring systems had failed to promptly identify serious and widespread concerns in the service that had negatively impacted on those people that used it.” from the report
- 01What specific changes have been made to assess and manage risks such as weight loss, swallowing difficulties, skin damage and people leaving the home?
- 02How do you now check that staff have the right experience, values and skills, and that they receive induction, supervision and competency checks?
- 03How are mental capacity assessments and best-interest decisions recorded, including for sensor mats and thickened fluids?
- 04How do you make sure care plans are accurate, reviewed regularly and followed by permanent and agency staff?
- 05What activities and support are now available, and how are people's communication, oral care and personal interests being included in their care?
This was a full inspection covering all five key questions, including infection prevention and control; the inspection visit took place on 28 June and record checks continued remotely until 5 July 2022. This explanation was written from the published report of 24 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Belvoir House
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- April 2023Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- August 2018
Registered with the Care Quality Commission on 23 August 2018.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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